Forearm Compartment Research Articles

Efficacy of Video-Based Forearm Anatomy Model Instruction for a Virtual Education Environment

Introduction: As virtual education becomes more widespread, particularly considering the recent COVID-19 pandemic, studies that assess the impact of online teaching strategies are vital. Current anatomy curriculum at Paul L. Foster School of Medicine consists of self-taught PowerPoint material, clinical vignette-centered team-based learning, and prosection-based instruction (wet lab). This study examined the impact of video-based instruction using a student-designed muscle model on anatomy quiz scores and student perceptions of its effectiveness on learning outcomes.Methods: Students divided into Group 1 (54 students) and Group 2 (53 students) were assessed prior to and following a 3.5-minute model-based video on anterior forearm compartment musculature. Group 1 received video instruction and assessment prior to the wet lab. Group 2 received video instruction and assessment following the wet lab. Both groups took an identical five-question quiz covering locations and functions of various anterior forearm muscles.Results: Mean scores were higher than no intervention with exposure to video alone (0.73 points, p=0.01), wet lab alone (0.88 points, p=0.002) and wet lab plus video instruction (1.35 points, p=Conclusion: Video-based muscle model instruction is comparable to prosection-based lab with regards to score outcomes and was well received by students as both an independent learning tool and as a supplement to cadaveric lab. When compared to model-based instruction or prosection-based instruction alone, the supplementation of anatomical models with cadaveric prosection instruction was best. Institutions transitioning to a virtual learning environment, or those with limited in-person contact hours, cadaveric donors or trained anatomy faculty can benefit from the incorporation of video-based instruction into their anatomy curriculum.

Simultaneous 4 Compartment Pressure Monitoring in Diagnosis of Chronic Exertional Compartment Syndrome of the Forearm

The authors describe a technique for bilateral simultaneous measuring of forearm compartments pressure for assessment of suspected chronic exertional compartment syndrome of the forearm. Under ultrasound guidance, 18-G cannulae were inserted bilaterally into the superficial flexor and dorsal extensor forearm compartments. The imaging was used to confirm safe subfascial placement, and ensured no kinking or catching on the muscle bellies during dynamic movements. An arterial pressure transducer with 4 portals allowed simultaneous measurements from 4 compartments. Intracompartmental pressure (ICP) was measured in 2 ways, (1) hand in a relaxed position and (2) power grip with Jamar Dynamometer. After baseline measurements were taken, the patient undertook a period of rowing sufficient to generate symptoms. ICPs were then recorded at 1, 2, and 5 minutes by which time symptoms had resolved. Using this method ICPs in 4 myofascial compartments was measured in the same limb, simultaneously, pre- and postexercise.

Chronic Exertional Compartment Syndrome of the Forearm: Mini-invasive Technique Using an Endoscopic Soft Tissue Release System.

Chronic exertional compartment syndrome of the forearm is a rare disease characterized by the recurrent onset of forearm pain and progressive weakness during exertion. Over the years many surgical techniques have been reported in literature: wide-open fasciotomy, mini-open fasciotomy, fasciotomy associated with fasciectomy, and mini-invasive endoscopic fasciotomy. Compared with traditional open techniques, mini-invasive techniques are characterized by minimal tissue trauma, less postoperative pain, faster recovery to normal activity and better esthetical result. We describe a mini-invasive endoscopic technique for the treatment of forearm chronic exertional compartment syndrome using the SmartRelease endoscopic tissue release system (MicroAire).

Anatomical variations of the extensor tendons of the fetal thumb.

The extensor pollicis longus (EPL) and brevis (EPB) and abductor pollicis longus (APL) are muscles located in the posterior compartment of the forearm. These muscles allow the thumb to move independently from the other four fingers by attaching to the thumb separately. This study's goal was to investigate the tendon variations and insertions of these muscles. Our study was conducted on 43 fetal cadavers (86 upper extremities) aged between 17 and 40weeks of gestation. This study investigated the tendon numbers and insertions of the EPL, EPB, and APL. The tendon numbers of the EPL and EPB were observed to range between 1 and 2, and the tendon numbers of the APL ranged between 1 and 5. The EPL was found to insert into the distal phalanx via the dorsal aponeurosis in all extremities. It was observed that the EPB tendons inserted into the proximal phalanx, distal phalanx, and dorsal aponeurosis. It was determined that the APL tendons inserted into the basis of the first metacarpal, abductor pollicis brevis, opponens pollicis, and trapezium bone. Knowing the tendon variations and insertions of the EPL, EPB, and APL muscles during the fetal period will be useful in planning treatments to correct the congenital thumb anomalies and the loss of function after injury.

Volar Radiocarpal Ligament Repair with Suture Anchors for Radiocarpal Fracture Dislocations: Case Series.

Background Radiocarpal fracture dislocations cause significant intraarticular disruption and instability difficult to treat with traditional plating methods. Description of Technique Suture anchor fixation of the volar radiocarpal ligaments through an extended carpal tunnel approach, supplemented with radial styloid fixation, restores stability to the radiocarpal joint. Patients and Methods We performed a retrospective review of 14 consecutive radiocarpal fracture-dislocations (RCFDs) treated at two-level one trauma center from 2011 to 2015. In all cases, the volar radiocarpal ligaments were repaired to the distal radius with suture anchors. Results We reviewed 14 Dumontier Group 2 RCFDs in 14 patients (10 males, four females) with an average age of 39 years (range 22-53 years). Final follow-up averaged 288 days (range 7-1,364 days). Surgeons performed volar ligament repair with suture anchors in all cases, radial styloid fixation in 79% (11/14), and dorsal plate fixation in 29% (4/14). Eight of 14 patients (57%) had a "flipped" volar lip fragment of the distal radius. Three patients had forearm compartment syndrome and two patients had acute carpal tunnel syndrome. No patients experienced radiocarpal subluxation after volar ligament repair. Conclusion No recurrent subluxation or dislocation occurred after primary repair of the volar radiocarpal ligaments using suture anchors in this series of radiocarpal fracture dislocations. Volar radiocarpal ligament repair also addressed the "flipped" volar rim fragment that could not be addressed through a dorsal approach alone. Level of Evidence : This is a Level IV, case series therapeutic study.

Telemedicine-guided forearm emergency decompressive fasciotomy for compartment syndrome

Introduction We highlight the utility of telemedicine and telementoring for the management of orthopaedic emergencies using a case of forearm compartment syndrome following a penetrating trauma in a northern Inuit community in Nunavik, Quebec, Canada. Methods & Results As in many cases of compartment syndrome in rural settings, the patient was at a high risk of developing irreversible complications. A prompt diagnosis followed by an emergency decompressive fasciotomy was warranted. Using telemedicine and telementoring guidance, the diagnosis of compartment syndrome was made, and the patient’s volar compartment was successfully decompressed by a local emergency physician in a timely manner. Subsequently, the patient was able to be safely transferred to a level 1 trauma centre for further surgical management. This included a second-look operative exploration, irrigation and debridement, completion of volar fasciotomy and ulnar nerve decompression. No complications were seen. Discussion Our experience highlights two important clinical implications. First, telemedicine can be successfully implemented to facilitate clinical diagnosis of surgical emergencies in the rural setting. Second, telementoring can effectively allow surgeons to guide physicians remotely to perform emergency decompressive fasciotomy, which can help salvage the affected limb and significantly decrease the risk of debilitating complications.

Imaging of the lesions in the lateral muscle compartment of the forearm, alias mobile wad of Henry: Demographics, radiological anatomy and surgical relevance

IntroductionMobile wad of Henry (MOH) is a preferred surgical term used to describe the lateral compartment muscles of the forearm consisting of brachioradialis, extensor carpi radialis longus and brevis. The lesions in this compartment are uncommon. In this paper, we describe the largest series of the MOH lesions including their demographics, imaging appearances and importance of surgical anatomy whilst managing MOH lesions via radiological or surgical interventions. MethodsA retrospective search of oncology database for lesions in MOH at our tertiary orthopaedic oncology institute was performed for the last 12 years (2007–2019) after obtaining institutional review board approval. We further analyse data to obtain further clarity of various neoplasms occurring at this particular anatomical site. ResultsWe identified 28 patients with MOH lesions with an age range of 8 to 84 years and a male predominance. Imaging-wise, majority of lesions were benign following characteristics of lipomatous tumours, lipomas being the commonest. Other relatively uncommon benign lesions were nodular fasciitis, myositis ossificans and brachioradialis muscle injury; whereas aggressive MOH soft tissue neoplasms included synovial sarcoma and fibrohistiocytoma. ConclusionAlthough majority of MOH lesions are benign, one needs to be aware of spectrum containing uncommon benign and aggressive MOH lesions. When posed with dilemma, the MOH lesions require multidisciplinary approach with close collaboration of the radiologist, the surgeon and the pathologist to decide further management.

Limb Transplantation Following Ex Vivo Normothermic Perfusion in an Orthotopic Forelimb Swine Transplantation Model

PURPOSE: Ischemia-reperfusion injury remains a major limiting factor for limb replantation and transplantation. Ex-vivo normothermic limb perfusion has been proven to preserve viability and function of amputated limbs longer than cold storage. Our aim was to investigate the feastibility of limb transplantation following EVNLP and possible vascular, inflammatory and infectious complications in a mid-humerus porcine forelimb transplant model. METHODS: Eight Yucatan miniature pigs, 4 donors and 4 recipients, were used. Right forelimbs of donor animals were amputated at mid-humeral level, to maintain integrity of forearm fascial compartments, and preserved with EVNLP until replantation. The right forelimb of the recipient animal was amputated, and a central venous line was placed in the contralateral neck. Perfusate electrolytes, gases, O2 saturation, muscle contractility, surface temperature (infrared thermography), and peripheral perfusion (indocyanine green agiography) were assessed during EVNLP. The humerus was fixed with a single 3.5 mm LC-DCP plate; microsurgical anastomosis of the brachial artery, cephalic vein, and repair of radial, ulnar, and median nerves were performed under an operative microscope. Tendons of the biceps and triceps were repaired with pulvertaft weave technique. The first animal did not receive systemic immunosuppression. Systemic immunosuppression for the remaining 3 pigs included induction with antithymoglobulin, followed by daily cyclosporine (CSA), mycophenolate mofetil, and methylprednisolone. CSA trough levels were measured daily. Limbs were monitored clinically and histologically for signs of rejection. Bone healing was confirmed with CT scan at euthanasia. The endpoint of the study was 90 days. RESULTS: Warm ischemia time during limb procurement was 20.6 ± 9 minutes and 2.2 ± 0.25 hours during limb transplantation. EVNLP lasted an average of 4.3 ± 0.52 hours. Total time to revascularize was 6.8 ± 0.5 hours. PO2, pH, and lactate were 557 ± 72 mm Hg, 7.5 ± 0.1, 5.6 ± 0.9 mmol/L, respectively. Muscle contractions were 4/5 during EVNLP. All forelimbs were successfully transplanted with no vascular failure. CSA trough levels were on average 678 ± 450, 369 ± 445, and 336 ± 468 ng/ml. Animals 2, 3, and 4 developed septic thrombophlebitis of the central line, which was replaced on POD 14, 51, and 28. Animals 3 and 4 lost IV access on POD 54 and 64, respectively, and were transitioned to PO medications. The first transplanted limb (animal 1) showed evidence of acute rejection on POD 4 and the animal was euthanized on POD 6. In the remaining animals, the incisions healed and initial edema resolved by day 14.The third animal developed angioinvasive aspergillosis on POD 20 with 2 areas of full thickness skin necrosis of trunk. Voriconazol was started and the lesions were resected on POD 51. The animal lost the central line on POD 55, showed evidence of rejection on POD 57 and was euthanized on POD 60. Animals 2–4 showed bone healing and consolidation with the presence of bony callus on CT scans. At endpoint, animals 2 and 4 had reached complete weight bearing on the transplanted limb, at the hoof and wrist, respectively. CONCLUSION: Extremity transplantation can be successfully performed following EVNLP. EVNLP does not increase the risk of vascular or infectious complications. The mid-humerus porcine transplantation model is feasible and reproducible.

Extensor Indicis Radialis and Extensor Medii Proprius Associated with an Unknown Fibromuscular Slip: a Case Report

Posterior compartment of forearm and hand is among the most variable parts of the human body. During a routine dissection, we found two anatomical variants in the right forearm and hand of an 84-year-old male cadaver including the extensor indicis radialis and the extensor medii proprius associated with a fibromuscular slip. Histological analysis using hematoxylin and eosin staining revealed that this unusual fibromuscular slip associated with the extensor medii proprius was composed of dense connective tissue along with small amount of skeletal muscle fibers, and the innervation from the posterior interosseous nerve. Based on the existing literature, a fibromuscular slip associated with a hand extensor tendon on the dorsum of hand has never been reported. Further studies are needed to clarify the evolutionary origin of this structure, although it resembles to a certain extent the dorsometacarpales, a group of muscles that were once present in our mammalian ancestors.

A New Single Volar Approach for Both-Bone Fractures of the Forearm: The Mediolateral Windows Approach Extended.

Fractures of the forearm are common injuries in adults. Particularly, both-bone fractures of the radius and ulna are frequently encountered by orthopedic surgeons. To date, these fractures are typically treated with open reduction and internal fixation, because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. We propose a modification of the classic double approach for both-bone fractures of the distal radius and ulna. Indeed, we described a minimal and anatomic approach to prevent complications such as the heterotopic ossification of the interosseus membrane and vascular-nervous lesions. By a single anterior incision, we utilize 2 windows to expose the medial and lateral compartments of the forearm. In this way, we avoid the handling of the interosseous membrane, and we protect the ulnar, median, and radial nerves from the surgical approach. This technique is indicated for complex distal radius and ulna fractures. We exclude open fractures, and Monteggia, Galeazzi, or Essex-Lopresti lesions. In this report, we describe the surgical anatomy, surgical approach, and complications regarding this approach.

Clinical Significance of a Duplicated Palmaris Longus Muscle with One Reversed Muscle: A Case Report

BACKGROUND: Multiple variations of the palmaris longus (PL) muscle are reported throughout literature and include variations such as double muscle bellies, inversion of muscle belly and tendon, and the absence of the muscle. The muscle functions as a weak flexor of the wrist. It originates from the medial epicondyle of the humerus, projects as a superficial muscle of the anterior compartment of the forearm, lies over the transverse carpal ligament, and inserts into the palmar aponeurosis.
 CASE REPORT: Routine dissection of the right forearm of a 70-year-old Caucasian male revealed a rare duplicated PL muscle with the medial PL muscle being reversed. The left forearm appeared normal, with no such variations. The cadaver showed no significant pathological findings due to this variation. Innervation and vasculature of the variant muscle appeared normal.
 CONCLUSION: The PL muscle is highly variable, and clinicians need to be aware of its many possible presentations due to its involvement in surgery, symptomatic clinical presentations, and as an anatomical landmark.

The Gantzer Muscle: An Expanded Study of this Variant Forearm Muscle

Gantzer muscles are anatomical variations found within the flexor compartment of the forearm. The Gantzer muscle typically arises from the flexor digitorum superficialis (FDS) and inserts into the flexor pollicis longus (FPL) or flexor digitorum profundus (FDP). The presence of this muscle can cause various compressive injuries, including neuropathy of the median or anterior interosseous nerve and impingement of the ulnar, common, or anterior interosseous arteries. Despite its high prevalence, the Gantzer muscle is often excluded from the differential for acute compartment syndrome and should be further considered during treatment and surgical management. This study expanded upon a previous assessment of cadaveric specimen forearms to determine further the prevalence of origin, insertion, and innervation of Gantzer muscles, as well as possible compressions induced from impingement by the anomalous muscle. A total of 288 limbs were dissected in 144 cadavers. The Gantzer muscle was found in 54.6% (148:271) of limbs. Therefore, in general, the Gantzer muscle is more likely to be present than absent. This report also details common and uncommon origins and insertions of Gantzer variants.Support or Funding InformationT. Walley Williams Summer Anatomy Research Fellowship; WV Research Challenge Fund [HEPC.dsr.17.06]

Acute compartment syndrome of the forearm associated with transradial coronary intervention.

This study documents our experience with acute forearm compartment syndrome after percutaneous transradial coronary artery intervention and suggests several strategies to achieve good results. A retrospective review identified the medical records of four patients with acute forearm compartment syndrome after transradial intervention who were treated by urgent fasciotomy. The mean time from the onset of symptoms to operation was 5.7hours. In three cases bleeding was from radial artery rupture at the puncture site, and one case was caused by brachial artery rupture at the level of the distal humerus and radial artery rupture at the level of proximal forearm. We obtained satisfactory results without any complications. If acute forearm compartment syndrome after transradial intervention is diagnosed, the site of bleeding should be identified preoperatively. Early surgical decompression produced satisfactory results even in elderly patients.Level of evidence: IV.

A bilateral variant accessory belly of extensor indicis muscle in posterior compartment of forearm: An anatomical variation

A bilateral variant accessory belly of extensor indicis muscle in posterior compartment of forearm: An anatomical variation

Factors Associated With Poor Outcomes in Acute Forearm Compartment Syndrome.

Background: There is limited literature on risk stratification of patients with acute forearm compartment syndrome. The primary objective of this study was to identify factors associated with poor outcomes in patients with acute forearm compartment syndrome. Methods: We retrospectively identified 130 patients with acute compartment syndrome of 130 forearms treated with fasciotomies from January 2000 to June 2015 at 2 Level 1 trauma centers. Poor outcome was defined as a composite variable, including: (1) death; (2) limb amputation; (3) persistent neurological deficit; and (4) contracture. Patient- and treatment-related variables were collected. Bivariate analyses were used to screen for variables associated with poor outcome, and explanatory variables with a value of P < .05 were included in our multivariable logistic regression analyses. Results: Of the 130 patients, 43 (33%) with acute forearm compartment syndrome had poor outcomes, including 5 deaths, 5 limb amputations, 21 persistent neurological deficits, and 31 contractures. Multivariable logistic regression analyses showed that elevated serum creatine kinase at presentation (P < .05) was associated with poor outcomes in patients with acute forearm compartment syndrome. Receiver operating characteristic curve analysis showed that a serum creatine kinase cutoff of 300 U/L yields 92% sensitivity and a serum creatine kinase cutoff of 10 000 U/L yields 95% specificity for poor outcomes in acute forearm compartment syndrome. Conclusions: Elevated creatine kinase levels above 300 U/L are a useful screening test for the highest risk patients with acute forearm compartment syndrome. Levels above 10 000 U/L may play a role in informed consent and counseling regarding expectations.

Distribution of intramuscular giant lipomas in the functional compartments of the forearm: a report of 12 cases.

The aim of this study was to investigate the distribution of intramuscular giant lipomas in the functional compartments of the forearm and to compare their clinical, radiological and histopathological features with those reported in the current literature. The study included 12 patients who were surgically treated for intramuscular lipomas > 5 cm in size located in the forearm that had been confirmed histopathologically between April 2006 and March 2017. Data about the patients with respect to age, sex, affected side, localisation of the lipomas in the forearm functional compartments, size, histopathological features and recurrence were collected. According to the clinical complaints, direct radiography and magnetic resonance imaging were applied. The average diameter was 6.5 cm (range: 5.5-9 cm). All lipomas had a well-defined border. All the patients presented with soft-tissue masses that were painless in seven patients. Five patients had nerve compression symptoms. When the lipomas were classified according to the functional compartments of the forearm, six of them were located in the superficial volar compartment, two in the deep volar compartment, two in the deep dorsal compartment and two in the lateral compartment. All lipomas were surgically removed by marginal excision. None had complications or recurrence at a mean of 6.5 years follow-up (range: 1-12 years) after surgery. Intramuscular lipoma is a relatively uncommon tumour, especially in the forearm. Because of the proximity to the neurovascular structures in the forearm, excision of lipomas should be performed with care and include wide incisions. Additionally, knowing the anatomical features of the compartment where the lipoma is localised in the forearm is important in planning surgery to enable easier dissection of the lipoma and lessen the risk of damage to adjacent neurovascular structures. Level 4.

Sonoanatomy of anterior forearm muscles.

The anterior or volar compartment of the forearm contains eight muscles: five belong to the superficial group (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris), and three to the deep group (flexor digitorum profundus, flexor pollicis longus and pronator quadratus). Knowledge of the topographic anatomy is essential for correct performance of ultrasound (US) examinations and correct interpretation of the images provided.

Negative pressure wound therapy as a definitive treatment for upper extremity wound defects: A systematic review.

Negative pressure wound therapy (NPWT) represents one of the many solutions for complex wounds of the upper extremity. The goal of this study was to investigate the most common indications for definitive treatment of wound defects in the upper extremity with NPWT and to report revision surgery outcomes after its use. A systematic review of the literature was performed. The following keywords and their combinations were used: "upper extremity," "arm," "forearm," "wrist," "hand," "finger" AND "negative-pressure wound therapy," "VAC therapy," "vacuum assisted closure." A total of 45 articles were included, regrouping 404 cases of NPWT in the upper extremity. The forearm was involved in 53% of cases, followed by hand (36%), fingers (10%), and arm (1%). Seventeen different indications were cited, the most common of which were radial forearm flap reconstruction (23%), burn wounds (18%), and compartment syndromes (17%). Of the cases, 90% did not require any subsequent surgical procedure, as opposed to 6% considered partial failures requiring minor revisions and 4% total failures requiring major revisions. Closure of radial forearm flap donor site required the most revision procedures when treated with NPWT. NPWT can be used for several indications pertaining to the reconstruction of the upper extremity. Positive outcomes as a definitive treatment are demonstrated in this systematic review, which reaffirms NPWT as a potent tool for reconstructive endeavours.

Notes on the Accessory Flexor Carpi Ulnaris Muscle: A Rare Supernumerary Variation

AbstractVariations of the forearm muscles are well described in the literature. In spite of that, reports regarding the accessory flexor carpi ulnaris muscle are scarce due to its rarity. This muscle usually originates from the medial epicondyle of the humerus with the flexor muscle mass and inserts itself into the palmar aponeurosis or the pisiform bone together with the flexor carpi ulnaris muscle. Supernumerary and anomalous muscles of the anterior compartment of the forearm have been associated with ulnar nerve and artery compression. Furthermore, they may also mimic neuromas and soft tissue tumors. The study of supernumerary muscles is necessary, as they may be an option to tendon grafts and muscle flaps. The aim of this paper is to describe the presence of the accessory flexor carpi ulnaris muscle on the left forearm of a cadaver fixated in a phenol solution and discuss its clinical and anthropological significance.

Acute Traumatic Compartment Syndrome of the Forearm: Literature Review and Unfavorable Outcomes Risk Analysis of Fasciotomy Treatment.

Forearm compartment syndrome is a relatively underreported event compared with compartment syndrome of the lower extremity or trunk. The aim of this review of the literature was to provide insight into the potential consequences of certain treatment modalities in the control of acute compartment syndrome of the forearm based on data presented over the past 44 years. A comprehensive search was conducted across several databases including EMBASE, Ovid MEDLINE, Cochrane Database of Systematic Reviews, and Scopus, capturing studies published from 1973 to 2017 to identify potential articles for inclusion in the review. Outcomes data were evaluated for each of the studies included in this analysis on the basis of treatment utilized (fasciotomy vs. no fasciotomy) and respective outcome (favorable vs. unfavorable). Relative risk (RR) analysis was performed to determine risk factors for unfavorable outcomes from the pooled data. The analysis revealed a statistically significant higher likelihood of unfavorable outcomes resulting from performing fasciotomy in the event of forearm compartment syndrome compared with conservative management (RR = 4.82, p < .01). Fasciotomy treatment was associated with a higher likelihood of patients presenting with forearm compartment syndrome to experience unfavorable outcomes. The results of this study can help guide awareness of potential sequelae of treatment choices in forearm compartment syndrome, and clinical decision-making for wise patient selection for surgical intervention, when necessary.